3018 Not Only Bullets Kill in War: A Case Report of Klatskin Tumor in a Veteran

Abstract

INTRODUCTION: Cholangiocarcinoma (CAA) is a rare GI malignancy in the United States with a reported incidence of 1-2 per 100,000 person. Classification is based on location within the biliary tree with 50% of cases occurring at the perihilum. CAA located at the bifurcation of the common hepatic duct are called Klatskin tumors. Curative treatment is by complete resection versus palliative approach to non-resectable tumors. CASE DESCRIPTION/METHODS: 77 year old male veteran with history of CAD, DM II, and CKD III presented to the emergency department with sudden onset, painless jaundice associated with 20 pound weight loss, fatigue, and loss of appetite over the past 3 months. He appeared cachetic, jaundiced with scleral icterus noted. Abdomen was nontender without organomegaly. Diagnostic studies revealed ALP 1056, AST 266, ALT 416, and direct bilirubin 12. Abdominal US revealed cholelithiasis without biliary tract dilation or gallbladder wall thickening. MRCP showed obstruction at the hepatic hilum at the confluence of the left and right hepatic lobes with moderate intrahepatic bile duct dilation. ERCP revealed diffuse biliary ductal dilation with a mass in the common bile duct. EUS guided fine needle aspiration of the mass at the common hepatic duct was done. Bloodwork showed elevated levels of CEA. Complete staging showed a portocaval lymph node. Medical and surgical oncology teams agreed that the tumor was unresectable. Palliative gemcitabine and cisplatin were initiated. DISCUSSION: Risk factors for the development of CAA include hepatitis B, C, and primary sclerosing cholangitis. Vietnam war Veterans have unique risk factors including exposure to Agent Orange and parasitic infections including Clonorchis sinensis and Opisthorchisviverrini. Our patient spent 14 months on a naval base outside Cambodia. He admits exposure to raw and freshwater fish. The causal relationship between the two liver flukes and CAA is well documented. Of the 700 claims made to the Department of Veterans Affairs (VA), 75% have been rejected. Pilot prospective studies performed by the VA have shown exposure to these parasites in Vietnam veterans. To date, there is no commercial serologic test in the US to identify previous exposure to these parasites. Our case raises the question whether these veterans are at increased risk of CAA and whether there is any utility in screening for CAA in this population. Further studies are needed to establish whether this unique population is at increased rates for CAA.